- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,706.14 / $3,706.14 / $3,955.04
| Facility | | $3,706.14 | $3,706.14 | $3,955.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.26 / $531.29 / $795.11
| Professional | | $386.26 | $531.29 | $795.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.46 / $502.15 / $1,017.27
| Professional | | $367.46 | $502.15 | $1,017.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.07 / $751.94 / $889.27
| Professional | | $523.07 | $751.94 | $889.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.12 / $626.27 / $1,006.39
| Professional | | $311.12 | $626.27 | $1,006.39 |